Application "*" indicates required fields Merchant InformationBusiness Legal Name*Business DBA Name (If Applicable)Federal Tax ID*Business Start Date*Business Address*City*State*ZIP*Mailing Address*City*State*ZIP*Contact NameBusiness Type* LLC Sole Proprietor Corporations S Corporations PhoneBuilding TypeLocationEmail* Owner's Name & Title*Owner's Address*City*ZIP*Owner's DOBOwner's SocialDL#Owner's Percent of Ownership of BusinessMonthly Volume $Average Ticket $High Ticket $Currently Processing ? If "Yes", please provide most recent processing statement.Transaction Type (Retail Swiped, Mail-order/Telephone-order, or eCommerce):Swipe %Keyed %Internet %Website (If Applicable)What payment gateway, point-of-sale, or terminal is used to process payments?Cash Discount Yes No RateTran FeeEBT #Monthly Fee $TerminalShip To:Batch Close Disclaimer: Applicant authorize Swipe1 its Assigns, Agents, Banks of Financial Institutions to obtain an investigative or consumer report from a credit bureau or a credit agency and to investigate the references given on any other statement or data obtained from applicant. Applicant, b signing below, represents that all the information is complete and accurate.Signature
